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Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force. J Nurs Care Qual. 2017;32:354-358.
Stalter AM ; Phillips JM ; Dolansky MA; et al. White paper on recommendation for systems-based practice competency. QSEN Institute RN-BSN Task Force. 2017; 32: 354-358
A systems approach to practice has been advocated as a key element of safe medical care. This white paper proposes that systems-based practice be integrated as a nursing competency requirement, including education about organizational leadership and complexity science and systems theory in design.
Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2017;13:162-168.
Implementing human factors in clinical practice.
Timmons S, Baxendale B, Buttery A, Miles G, Roe B, Browes S. Emerg Med J. 2015;32:368-372.
Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.
Taylor CJC, Murphy MF, Lowe D, Pearson M. Qual Saf Health Care. 2008;17:239-243.
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. August 13-17, 2018; Constellation Energy Building, Baltimore, MD.
Human Factors and Technology in the ICU.
Wung SF, ed. Crit Care Nurs Clin North Am. 2018;30:179-310.
A call for a systems-thinking approach to medication adherence: stop blaming the patient.
Lauffenburger JC, Choudhry NK. JAMA Internal Med. 2018 May 21; [Epub ahead of print].
Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Management reasoning: beyond the diagnosis.
Cook CA, Sherbino J, Durning SJ. JAMA. 2018;319:2267-2268.
Deriving a framework for a systems approach to agitated patient care in the emergency department.
Wong AH, Ruppel H, Crispino LJ, Rosenberg A, Iennaco JD, Vaca FE. Jt Comm J Qual Patient Saf. 2018;44:279-292.
Standardized competencies for parenteral nutrition administration: the ASPEN Model.
Guenter P, Worthington P, Ayers P, et al; Parenteral Nutrition Safety Committee, American Society for Parenteral and Enteral Nutrition. Nutr Clin Pract. 2018;33:295-304.
Diagnostic performance dashboards: tracking diagnostic errors using big data.
Mane KK, Rubenstein KB, Nassery N, et al. BMJ Qual Saf. 2018;27:567-570.
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Patterson ES. Hum Factors. 2018;60:281-292.
Considering human factors and developing systems-thinking behaviours to ensure patient safety.
Vosper H, Lim R, Knight C, Bowie P, Edwards B, Hignett S; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2).
Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience.
Nix M, McNamara P, Genevro J, et al. Health Aff (Millwood). 2018;37:205-212.
Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators.
Hassen Y, Singh P, Pucher PH, Johnston MJ, Darzi A. Surgery. 2018;163:1226-1233.
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
Implementation of diagnostic pauses in the ambulatory setting.
Huang GC, Kriegel G, Wheaton C, et al. BMJ Qual Saf. 2018;27:492-497.
The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non–hospital-affiliated outpatient settings: a systematic review.
Berglas NF, Battistelli MF, Nicholson WK, Sobota M, Urman RD, Roberts SCM. PLoS ONE. 2018;13:e0190975.
The first U.S. study on nurses' evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes.
Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. Worldviews Evid Based Nurs. 2018;15:16-25.
Advancing perinatal patient safety through application of safety science principles using health IT.
Webb J, Sorensen A, Sommerness S, Lasater B, Mistry K, Kahwati L. BMC Med Inform Decis Mak. 2017;17:176.
A system-based approach to managing patient safety in ambulatory care (and beyond).
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose.
Fuchshuber P, Schwaitzberg S, Jones D, et al. Surg Endosc. 2018;32:2583-2602.
To err is human: use of simulation to enhance training and patient safety in anaesthesia.
Higham H, Baxendale B. Br J Anaesth. 2017;119(suppl 1):i106-i114.
Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature.
Prakash S, Mullick P, Kumar A, Pawar M. A A Case Rep. 2018;10:261-264.
Twelve tips for embedding human factors and ergonomics principles in healthcare education.
Vosper H, Hignett S, Bowie P. Med Teach. 2018;40:357-363.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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